HospitalInspections.org

Based on review of documents and interviews, it was determined that, for 1 of 1 (Pt. #1) grievance reviewed, the Hospital failed to adhere to their grievance policy.

Findings include:

1. Hospital policy entitled "Patient Grievances", revised date (7/2007) states: " Grievance means any complaint that falls in one of the following categories: 1.2.2 Certain Verbal Complaints. Any verbal (i.e. oral communications, non written) complaint by a patient that falls within the category: 1.2.2.1 Complaints Not Capable of Prompt Resolution. A verbal complaint not capable of prompt resolution by the staff present; 4.1 The designated hospital representative will complete the Complaint/Grievance Investigation Form.... forward to the appropriate individuals for initial investigations... 5.3 The designated representative will distribute copies of the Form with appropriate attachments, to the departments designated....5.4 the designated hospital representative will refer patient concerns regarding quality of care to the appropriate Quality Improvement Organization or Professional Review Organization in a timely manner. 6.1 Upon completion of the review of investigation, notification of outcome will be provided to the patient. "

2. The Director of Human Resource, E#1 conducted an investigation regarding Pt. #1's complaint of a rude employee who answered the phone on 12/8/12. E#1 was interviewed on 3/6/13 at approximately 12:00 PM. E#1 stated that she never reported the event to the hospital representative in charge of complaints and grievances since usually each manager of the department handles the patient complaints and " I thought that I resolved his issues when I did my investigation and provided him my findings and the manager 's name and number. However, he was not satisfied."

3. The Hospital's Complaint log was reviewed on 3/6/12. Pt.#1's complaint was not documented in the system.

4. At approximately 1:15 PM, the Director of Quality, E#3 was interviewed. E#3 explained that usually when the hospital receives a complaint it is entered in a complaint log and the manager of the department usually fills the form out or sometimes it comes via e-mail. The Quality Department enters it in the system (computer), then the hospital responds via a letter. It is discussed in the Leadership meeting and then at the Board level.

E#3 stated she was not aware of any patient complaints from the Radiology Department and Human Resource Department. "Today (3/6/13) is the first time I am hearing about this complaint. "